from: Rapid Interpretation of EKG’sR wave for Right Ventricular Hypertrophy. S wave depth in V 1 … + R wave height in V 5 for Left Ventricular Hypertrophy. 5. INFARCTION (pages

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.Personal Quick Reference Sheets

from: Rapid Interpretation of EKG’sby Dale Dubin, MD

COVER Publishing Co., P.O. Box 07037, Fort Myers, FL 33919, USA

There is no need to remove these reference pages from yourbook. To download and print them in full color, go to:

May humanity benefit from your knowledge,

(pages 333 to 346)

6th Ed.

RAPIDINTERPRETATION

OF

EKG’s

Dale Dubin, MD

Dr. Dubin’s classic, simplified methodology for understanding EKG’s

Learning Web Sites:

Physicians and medical students: www.theMDsite.com

Nurses and nurses in training: www.CardiacMonitors.com

Emergency medical personnel: www.EmergencyEKG.com

www.theMDsite.com

“Reference Sheets”

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Personal Quick Reference Sheets

Dubin’s Methodfor

Reading EKG’s

1. RATE (pages 65-96)

Say “300, 150, 100” …“75, 60, 50”• but for bradycardia:

rate = cycles/6 sec. strip ✕ 10

2. RHYTHM (pages 97-202)

Identify the basic rhythm, then scan tracing for prematurity,pauses, irregularity, and abnormal waves.

• Check for: P before each QRS.QRS after each P.

• Check: PR intervals (for AV Blocks).QRS interval (for BBB).

• If Axis Deviation, rule out Hemiblock.

3. AXIS (pages 203-242)

• QRS above or below baseline for Axis Quadrant(for Normal vs. R. or L. Axis Deviation).For Axis in degrees, find isoelectric QRS in a limb leadof Axis Quadrant using the “Axis in Degrees” chart.

• Axis rotation in the horizontal plane: (chest leads)find “transitional” (isoelectric) QRS.

4. HYPERTROPHY (pages 243-258)

P wave for atrial hypertrophy.R wave for Right Ventricular Hypertrophy.S wave depth in V1… + R wave height in V5 for Left Ventricular Hypertrophy.

5. INFARCTION (pages 259-308)

Scan all leads for:

• Q waves• Inverted T waves• ST segment elevation or depression

Find the location of the pathology (in the Left ventricle),and then identify the occluded coronary artery.

CheckV1 {

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Rate (pages 65 to 96)

Determine Rate by Observation (pages 78-88)

Bradycardia (slow rates) (pages 90-96)

• Cycles/6 second strip ✕ 10 = Rate• When there are 10 large squares between similar waves, the rate is 30/minute.

Sinus Rhythm: origin is the SA Node (“Sinus Node”), normal sinus rate is 60 to 100/minute.

• Rate more than 100/min. = Sinus Tachycardia (page 68).• Rate less than 60/min. = Sinus Bradycardia (page 67).

Determine any co-existing, independent (atrial/ventricular) rates:• Dissociated Rhythms: (pages 155, 157, 186-189) A Sinus Rhythm (or atrial rhythms) may co-exist with an independent rhythm from an automaticity focus of a lower level. Determine rate of each.

Irregular Rhythms: (pages 107-111)

• With Irregular Rhythms (such as Atrial Fibrillation) always note the general (average) ventricular rate (QRS’s per 6-sec. strip ✕ 10) or take the patient’s pulse.

Fine division/rate association: reference (page 89)

May be calculated: 1500

= RATE mm. between similar waves

300 150 100 75 60

250

214

187

167

136

125

115

107

94

88

83

79

71

68

65

62

STA

RT

“300

”

“150

”

“100

”

“75” “60” “50”

Using the triplets:Name the lines following the “Start” line.

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★ Identify basic rhythm……then scan entire tracing for pauses, premature beats,

irregularity, and abnormal waves.

★ Always:• Check for: P before each QRS.

QRS after each P.• Check: PR intervals (for AV Blocks).

QRS interval (for BBB).• Has QRS vector shifted outside normal range? (to rule out Hemiblock).

Irregular Rhythms (pages 107-111)

Sinus Arrhythmia (page 100)

Irregular rhythm that varieswith respiration.All P waves are identical.

Considered normal.

Wandering Pacemaker (page 108)

Irregular rhythm. P waveschange shape aspacemaker location varies.

Rate under 100/minute…

…but if the rate exceeds100/minute, then it is called

Multifocal Atrial Tachycardia(page 109)

Atrial Fibrillation (pages 110, 164-166)

Irregular ventricular rhythm.Erratic atrial spikes(no P waves) frommultiple atrial automaticityfoci. Atrial dischargesmay be difficult to see.

Rhythm (pages 97 to 111)

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Rhythm continued (pages 112 to 145)

Escape (pages 112-121) – the heart’s response to a pause in pacing

•A

n u

nh

ea

lty S

inu

s (S

A)

No

de

ma

yfa

il to

em

it a

pa

cin

g s

timu

lus

(“S

inu

s B

lock

”);

this

pa

use

ma

ye

voke

an

esc

ap

e b

ea

t fr

om

an

au

tom

atic

ity f

ocu

s.

•B

ut

a s

ick

Sin

us

(SA

) N

od

e m

ay

cea

se p

aci

ng

(“S

inu

s A

rre

st”)

,ca

usi

ng

an

au

tom

atic

ity f

ocu

s to

“esc

ap

e”

to a

ssu

me

pa

cem

ake

rst

atu

s.

•A

n ir

rita

ble

au

tom

atic

ityfo

cus

ma

y su

dd

en

lyd

isch

arg

e,

pro

du

cin

g a

:

Premature Beats (pages 122-145) – from an irritable automaticity focus

Premature Atrial Beat(pages 124-130)

Premature Ventricular Contraction(pages 135-141)PVC’s may be:multiple, multifocal, in runs, orcoupled with normal cycles.

Premature Junctional Beat(pages 131-133)

pause

AtrialEscape Beat

or

or

VentricularEscape Beat

Then…

the SA Nodeusally resumespacing.Junctional

Escape Beat

(page 119)

(page 120)

(page 121)

++++

+

+

+

+

+

+

+

+++++

++

++++

+

+

+

+

+

+

+

+++++

++

++++

+

+

+

+

+

+

+

+++++

++

(page 114)

(pages 115-116)

(page 117)

(“idiojunctional rhythm”)

(“idioventricular rhythm”)

AtrialEscape RhythmRate 60-80/min.

or

or

JunctionalEscape RhythmRate 40-60/min.

VentricularEscape RhythmRate 20-40/min.

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Atrial FlutterA continuous (“saw tooth”) rapid sequenceof atrial complexes from a single rapid-firingatrial focus. Many flutter waves needed toproduce a ventricular response. (pages 159, 160)

Ventricular Flutter (pages 161, 162) also see “Torsades de Pointes” (pages 158, 345)

A rapid series of smooth sine waves from asingle rapid-firing ventricular focus; usually ina short burst leading to Ventricular Fibrillation.

Paroxysmal Atrial TachycardiaAn irritable atrial focus discharging at150-250/min. produces a normal wavesequence, if P' waves are visible. (page 149)

• P.A.T. with blockSame as P.A.T. but only everysecond (or more) P' waveproduces a QRS. (page 150)

Paroxysmal Junctional TachycardiaAV Junctional focus produces a rapidsequence of QRS-T cycles at 150-250/min.QRS may be slightly widened. (pages 151-153)

Paroxysmal Ventricular TachycardiaVentricular focus produces a rapid(150-250/min.) sequence of (PVC-like)wide ventricular complexes. (pages 154-158)

Rhythm continued (pages 146 to 172)

multiple foci discharging

Rates: ParoxysmalTachycardia Flutter Fibrillation

150 250 350 450

Tachyarrhythmias (pages 146-172), “focus” = automaticity focus

“Sup

rave

ntri

cula

r Ta

chyc

ardi

a”(p

age

153)

Fibrillation …erratic (multifocal) rapid discharges at 350 to 450/min. (pages 167-170)

Atrial Fibrillation (pages 110, 164-166)Multiple atrial foci rapidly dischargingproduce a jagged baseline of tiny spikes.Ventricular (QRS) response is irregular.

Ventricular Fibrillation (pages 167-170)Multiple ventricular foci rapidly dischargingproduce a totally erratic ventricular rhythmwithout identifiable waves. Needs immediatetreatment.

Paroxysmal (sudden) Tachycardia …rate: 150-250/min. (pages 146-163)

fusion

Flutter …rate: 250-350/min.

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1° AV Block …prolonged PR interval (pages 176-178).PR interval is prolonged to greaterthan .2 sec (one large square).

2° AV Block … some P waves without QRS response (pages 179-185)

Wenckebach …PR gradually lengthens with each(pages 180-182, cycle until the last P wave in the183) series does not produce a QRS.

Mobitz …some P waves don’t produce a QRS(pages 181-183) response. If “intermittent,” an

occasional QRS is droped.

More advanced Mobitz block mayproduce a 3:1 (AV) pattern or evenhigher AV ratio (page 181).

2:1 AV Block …may be Mobitz or Wenckebach.(pages 182, 183) PR length and QRS width or

vagal maneuvers help differentiate.

3° (“complete”) AV Block …no P wave produces a QRS response (pages 186-190)

3° Block: P waves—SA Node origin.(page 188) QRS’s—if narrow, and if the

ventricular rate is 40 to 60 per min.,then origin is a Junctional focus.

3° Block: P waves—SA Node origin.(page 189) QRS’s—if PVC-like, and if the

ventricular rate is 20 to 40 per min.,then origin is a Ventricular focus.

Sinus (SA) Block (page 174)

An unhealthy Sinus (SA) Node misses one or more cycles (sinus pause)…the Sinus Node usually resumes pacing, butthe pause may evoke an “escape” responsefrom an automaticity focus. (pages 119-121)

★ Always Check:• has Axis shifted

outside Normalrange?

★ Always Check:• is QRS within

3 tiny squares?

★ A

lway

s C

hec

k:• P

R in

terv

als

less

than

one

larg

e sq

uare

?

• Is

ever

y P

wav

e fo

llow

ed b

y a

QR

S?

Rhythm: (“heart”) blocks (pages 173 to 202)

Caution:With Left BBBinfarction is difficultto determine on EKG.

Right BBB (pages 194-196) Left BBB (pages 194-197)

R

QRS in V1 or V2

R'R

QRS in V5 or V6

R'With Bundle BranchBlock the criteria for

ventricular hypertrophyare unreliable.

AV Block (pages 176-189)

Blocks that delay or prevent atrial impulses from reaching the ventricles.

Bundle Branch Block …find R,R' in right or left chest leads (pages 191-202)

Hemiblock …block of Anterior or Posterior fascicle of the Left Bundle Branch.(pages 295-305)

Anterior Hemiblock Posterior HemiblockAxis shifts Leftward ➞ L.A.D. Axis shifts Rightward ➞ R.A.D.

look for Q1S3 look for S1Q3

(pages 297-299) (pages 300-302)

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Lead AVF

Lead I

Axis (pages 203 to 242)

Extreme Right Axis Deviationlead Axis

IAVL

IIIAVF

–90°–120°–150°–180°

Right Axis Deviationlead AxisAVF

IIAVR

I

+180°+150°+120°

+90°

Left Axis Deviationlead Axis

IAVR

IIAVF

–90°–60°–30°

0°

Normal Rangelead AxisAVF

IIIAVL

I

0°+30°+60°+90°+90o

-90o

+60o

-60o

+30o

-30o

0o

0o

L.

A.

D.

Normal R

ang

e

-90o

+90o

-120o

+120o

-150o

+150o

+180o

-180o

R.

A.

D.

Extr

eme R.A.D.

General Determination of Electrical Axis (pages 203-242)

Is QRS positive ( ) or negative ( ) in leads I and AVF?Is Axis Normal? (page 227) First Determine Axis Quadrant

(pages 214-231)

Axis in Degrees (pages 233, 234) (Frontal Plane)After locating Axis Quadrant, find limb lead where QRS is most isoelectric:

Normal:{

Axis Rotation (left/right) in the Horizontal Plane (pages 236-242)

Find transitional (isoelectric) QRS in a chest lead.

transitional QRSis “isoelectric”

QRS in lead I (pages 215-222)…if the QRS is Positive (mainly abovebaseline), then the Vector points topositive (patient’s left) side.

QRS upright in I and AVF“two thumbs-up” sign

QRS in lead AVF (pages 223-226)…if the QRS is mainly Positive, thenthe Vector must point downward topositive half of the sphere.

I

AVF

I

I

AVF

I

AVF

AVFL.A.D

.

R.A.D. Norm

al

R.A

.D.

Extre

me

Patient’sRight

Patient’sLeft

V1 V2 V3 V4V5

V6rotation

Normal Range

rotationLeftward

Rightward

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Atrial Hypertrophy (pages 245-249)

Right Atrial Hypertrophy (page 248)

• large, diphasic P wave with tall initial component

Left Atrial Hypertrophy (page 249)

• large, diphasic P wave with wide terminal component

Ventricular Hypertrophy (pages 250-258)

Right Ventricular Hypertrophy (pages 250-252)

• R wave greater than S in V1, but R wave gets

progressively smaller from V1 - V

6.

• S wave persists in V5 and V

6.

• R.A.D. with slightly widened QRS.• Rightward rotation in the horizontal plane.

Left Ventricular Hypertrophy (pages 253-257)

S wave in V1 (in mm.)

+ R wave in V5 (in mm.)

Sum in mm. is more than 35 mm. with L.V.H.

• L.A.D. with slightly widened QRS.• Leftward rotation in the horizontal plane.

Hypertrophy (pages 243 to 258)

Inverted T wave:slants downwardgradually,

but up rapidly.

terminalcomponent

Initialcomponent

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Q wave = Necrosis (significant Q’s only) (pages 272-284)

• Significant Q wave is one millimeter (one small square)wide, which is .04 sec. in duration…… or is a Q wave 1/3 the amplitude (or more)of the QRS complex.

• Note those leads (omit AVR) where significant Q’s are present… see next page to determine infarct location, and to identifythe coronary vessel involved.

• Old infarcts: significant Q waves (like infarct damage) remainfor a lifetime. To determine if an infarct is acute, see below.

ST (segment) elevation = (acute) Injury (pages 266-271) (also Depression)

• Signifies an acute process, ST segment returns tobaseline with time.

• ST elevation associated with significant Q wavesindicates an acute (or recent) infarct.

• A tiny “non-Q wave infarction” appears as significantST segment elevation without associated Q’s. Locate byidentifying leads in which ST elevation occurs (next page).

• ST depression (persistent) may represent “subendocardialinfarction,” which involves a small, shallow area just beneaththe endocardium lining the left ventricle. This is also a varietyof “non-Q wave infarction.” Locate in the same manner as forinfarction location (next page).

T wave inversion = Ischemia (pages 264, 265)

• Inverted T wave (of ischemia) is symmetrical (left halfand right half are mirror images). Normally T wave isupright when QRS is upright, and vice versa.

• Usually in the same leads that demonstrate signs ofacute infarction (Q waves and ST elevation).

• Isolated (non-infarction) ischemia may also be located;note those leads where T wave inversion occurs, thenidentify which coronary vessel is narrowed (next page).

NOTE: Always obtain patient’s previous EKG’s for comparison!

Infarction (pages 259 to 308)

Q

elevation

inversion

T

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Infarction Location— and —

Coronary Vessel Involvement(pages 259 to 308)

Coronary Artery Anatomy (page 291)

Infarction Location/Coronary Vessel Involvement (pages 278-294)

Posterior• large R with

ST depression in V1 & V2• mirror test or reversed

transillumination test(Right Coronary Artery)(pages 282-286)

Inferior(diaphragmatic)Q’s in inferior leads

II, III, and AVF(R. or L. Coronary Artery)(pages 281, 294)

LateralQ’s in lateral leads I and AVL(Circumflex Coronary Artery)(pages 280, 292)

AnteriorQ’s in V1, V2, V3, and V4(Anterior Descending

Coronary Artery)(pages 278, 292)

anteriordescending

circumflex

Left CoronaryArtery

Right CoronaryArtery

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Pulmonary Embolism (pages 312, 313)

• S1Q

3

3 – wide S in I, large Q and inverted T in III

• acute Right BBB (transient, often incomplete)• R.A.D. and rightward rotation (horizontal plane)• inverted T waves V

1 ➞ V

4 and ST depression in II

Artificial Pacemakers (pages 321-326)

Modern artificial pacemakers have sensing capabilities and also provide aregular pacing stimulus. This electrical stimulus records on EKG as a tinyvertical spike that appears just before the “captured” cardiac response.

• are “triggered” (activated) whenthe patient’s own rhythm ceasesor slows markedly.

• are “inhibited” (cease pacing)if the patient’s own rhythmresumes at a reasonable rate.

• will “reset” pacing(at same rate) tosynchronize with apremature beat.

(Asynchronous) Epicardial PacemakerVentricular impulse not linked to atrial activity.

Atrial Synchronous Pacemaker (page 323)P wave sensed, then after a brief delay,

ventricular impulse is delivered.

External Non-invasive Pacemaker(page 326)

Ventricular Pacemaker (page 323)(electrode in Right Ventricle)

Atrial pacemaker (page 323)

Dual Chamber (AV sequential) Pacemaker(page 323)

Miscellaneous (pages 309 to 328)

T

PVC stops pacemaker, but…

Dem

and

Pac

emak

ers:

(pa

ge 3

22)

Pacemaker Impulse (delivery modes)pacemaker resumes in step

with premature beat.

▼ ▼ ▼ ✕

▲ ▲ ▲

pacemaker spikes

sinus rhythm ceases

patient’s sinus rhythminhibits pacemaker

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Miscellaneous continued

U

wide,notched

P

wide QRS

long QT interval

ST

ElectrolytesPotassium (pages 314, 315)

Increased K+ (page 314)(hyperkalemia)

Decreased K+ (pages 315)(hypokalemia)

Calcium (page 316)

Digitalis (pages 317-319)

EKG appearance with digitalis (“digitalis effect”)• remember Salvador Dali.• T waves depressed or inverted.• QT interval shortened.

Digitalis Excess Digitalis Toxicity(blocks) (irritable foci firing rapidly)• SA Block • Atrial Fibrillation• P.A.T. with Block • Junctional or Ventricular Tachycardia• AV Blocks • multiple P.V.C.’s• AV Dissociation • Ventricular Fibrillation

Quinidine (page 320)

• EKG appearance with quinidine (page 320)

• Excess quinidine or other medicationsthat block potassium channels (or evenlow serum potassium) may initiateTorsades de Pointes (page 158) Torsades de Pointes

moderate extreme

moderate extreme

Hyper Ca++ Hypo Ca++

short QT prolonged QT

wide,flat P

peaked T

wide QRS

no P

flat T

Quinidine Effects

prominentU wave

QRS widens

U wav

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Dubin’s Quickie Conversion—for—

Patient’s Weight from Pounds to Kilograms

Patient wt. in kg. = Half of patient’s wt. (in lb.) minus 1/10 of that value.

Examples: 180 lb. patient 160 lb. patient 140 lb. patient(becomes 90 minus 9) (becomes 80 minus 8) (becomes 70 minus 7)

is 81 kg is 72 kg is 63 kg.

Modified Leads—for—

Cardiac MonitoringLocations are approximate. Some minor adjustment of electrode posi-

tions may be necessary to obtain the best tracing. Identify the specificlead on each strip placed in the patient’s record.

IdentificationSensor Electrode Letter Color (inconsistent)

+ R (or RA) red– L (or LA) white

G* G (or RL) variable* Ground, Neutral or Reference

Practical Tips

Modified Lead I Modified Lead II

G

G

G

G

Conventional Lead MCl1

To make this MCl6

move ●● electrodeto same(mirror)position onthe patient’sleft chest.

+

Documents

from: Rapid Interpretation of EKG’sR wave for Right Ventricular Hypertrophy. S wave depth in V 1 … + R wave height in V 5 for Left Ventricular Hypertrophy. 5. INFARCTION (pages